For NHS managers it is important to get a handle on the famous social psychology theory of 'cognitive dissonance'

The idea behind cognitive dissonance is that we like to think of ourselves as rational, reasonable and consistent beings and therefore if we notice our performance is not consistent we tend to modify our attitudes so that we can feel consistent again. This drive for consistency is so powerful that it can have a massive, yet often unconscious, effect on our attitudes and behaviour.

Cognitive dissonance theory, for example, accounts for the puzzling tendency of people who work in hazardous industries to ignore safety regulations more than those who do not work in such dangerous jobs.

The argument goes something like this: those who toil in a dangerous occupation must experience dissonance between their choice to work in such a hazardous area and their fear of injury. It is impossible to keep turning up to work in a state of high anxiety; and it is impossible to reconcile the idea that you are a rational intelligent person with the thought that you are making the dumb decision to put yourself in danger.

Reducing dissonance in this context takes the form of minimising in your own mind the probability of injury. Because you mentally resolve the conflict by deciding the danger is not that great, you come to think the daily risk is less serious than would those who are not exposed to it every day.

Another example is the way that the longer we are forced to wait for a thing the more valuable we decide it is.

Cognitive dissonance argues that the longer we wait for something, the more likely we are to believe that the wait was worth it. It gives us a way of maintaining our view of ourselves as sensible people who would not wait forever for something trivial.

Basically then, the more a thing costs us in money, waiting time, or any personal cost, the greater our need to justify our actions. So we alter our appreciation of the thing's value.

The implications of cognitive dissonance theory for the NHS are many. For example: the way managers tend to reconcile two conflicting demands - that of trying to deliver high quality patient care with that of balancing the budget.

One form of dissonance reduction that the theory predicts is that the manager might dehumanise patients, and not feel too concerned about how cuts would affect them as individuals.

Alternatively, dissonance reduction might lead to the manager making budget-balancing less of a priority.

However conflicts like these are resolved, they induce underlying stress. Managers need to be aware such stress may tempt them to reduce dissonance by jumping one way or another. And whatever jump they choose, a manager may be unaware that, if everyone else is reducing dissonance in the same way, it is bringing about a change in attitude.

Managers may need to challenge the underlying assumptions of attitude change so that they can be more aware of how much cognitive dissonance affects them.

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